Long-Term Outcomes of Cricothyroidotomy Versus Endotracheal Intubation in Military Personnel: A Retrospective Comparative Analysis Cohort Study.

INTRODUCTION: Emergency airway management is critical in trauma care. Cricothyroidotomy (CRIC) is a salvage procedure commonly used in failed endotracheal intubation (ETI) or difficult airway cases. However, more data is needed regarding the short and long-term complications associated with CRIC. This study aimed to evaluate the Israel Defense Forces experience with CRIC over the past 2 decades and compare the short-term and long-term sequelae of prehospital CRIC and ETI. METHODS: Data on patients undergoing either CRIC or ETI in the prehospital setting between 1997 and 2021 were extracted from the Israel Defense Forces trauma registry. Patient data was then cross-referenced with the Israel national trauma registry, documenting in-hospital care, and the Israel Ministry of Defense rehabilitation department registry, containing long-term disability files of military personnel. RESULTS: Of the 122 patients with short-term follow-up through initial hospitalization, 81% underwent prehospital ETI, while 19% underwent CRIC. There was a higher prevalence of military-related and explosion injuries among the CRIC patients (96% versus 65%, P = 0.02). Patients who underwent CRIC more frequently exhibited oxygen saturations below 90% (52% versus 29%, P = 0.002). Injury Severity Score was comparable between groups.No significant difference was found in intensive care unit length of stay and need for tracheostomy. Regarding long-term complications, with a median follow-up time of 15 y, CRIC patients had more upper airway impairment, with most suffering from hoarseness alone. One patient in the CRIC group suffered from esophageal stricture. CONCLUSIONS: This retrospective comparative analysis did not reveal significant short or long-term sequelae among military personnel who underwent prehospital CRIC. The long-term follow-up did not indicate severe aerodigestive impairments, thus suggesting that this technique is safe. Along with the high success rates attributed to this procedure, we recommend that CRIC remains in the armamentarium of trauma care providers. The findings of this study could provide valuable insights into managing difficult airway in trauma care and inform clinical decision-making in emergency settings.

A Nationwide, Population-based Study of Intelligence and Hearing Loss Among 3,104,851 Adolescents.

PURPOSE: Epidemiological studies have demonstrated a relationship between general intelligence (GI) in youth and hearing loss (HL). However, no large-scale study assessed the relations of GI in late adolescence with conductive HL and sensorineural HL, stratified by severity. This study examined the connection between HL and GI in late adolescence. METHODS: Cross-sectional study on mandatory pre-military recruitment data recorded during 1967-2019 of patients aged 17-19. We compared GI between sensorineural HL, conductive HL, and those with normal hearing. In addition, we used logistic regression to measure the associations between HL and GI after adjuring for age, sex, education, and socioeconomic status. RESULTS: Among 3,104,851 adolescents assessed, 20,075 (0.6%) exhibited hearing loss (HL). We categorized general intelligence (GI) into three levels for analysis: low (lowest category), medium, and high (reference category). Adjusted odds ratios (ORs) revealed that sensorineural HL (SNHL) was associated with lower GI levels, with ORs ranging from 1.3 [95% CI 1.4-1.2] for the lowest GI category to 1.1 [95% CI 1.15-0.04] for the medium category. Conductive HL (CHL) also demonstrated significant associations, with ORs from 1.8 [95% CI 1.9-1.6] for the lowest GI level to 1.1 [95% CI 1.2-0.9] for medium. Further analysis revealed a statistically significant, severity-dependent relationship between SNHL and the odds of being in the lowest GI quartile (Q1). Specifically, the odds ratios for SNHL ranged from 1.2 [95% CI 1.1-1.3] to 1.3 [95% CI 1.1-1.5] as severity increased, indicating a strong link between greater SNHL severity and reduced cognitive performance. In contrast, CHL did not show a consistent correlation between its severity and GI outcomes, with an OR of 1.6 [95% CI 1.2-2.3] across severity levels. CONCLUSION: We report a strong relationship between HL and GI in late adolescence. Sensorineural HL, but not conductive HL, demonstrated a severity-based decline in GI. The results highlight the value of early, specifically targeted therapies for HL that consider its etiology and degree.

When to choose intraosseous access in prehospital trauma care: A registry-based study from the Israel Defense Forces.

PURPOSE: Prompt vascular access is crucial for resuscitating bleeding trauma casualties in prehospital settings but achieving peripheral intravenous (PIV) access can be challenging during hemorrhagic shock due to peripheral vessel collapse. Early intraosseous (IO) device use is suggested as an alternative. This study examines injury characteristics and factors linked to IO access requirements. METHODS: A registry-based cohort study from the Israel Defense Forces Trauma Registry (2010 - 2023) included trauma casualties receiving PIV or IO access prehospital. Casualties who had at least one documented PIV or IO access attempt were included, while those without vascular access were excluded. Casualties requiring both PIV and IO were classified in the IO group. Univariable logistic regression assessed the factors associated with IO access. Results were reported as odds ratios (OR) with 95% confidence intervals (CI), and significant difference was set at p < 0.05. RESULTS: Of 3462 casualties (86.3% male, the median age: 22 years), 3287 (94.9%) received PIV access and 175 (5.1%) had IO access attempts. In the IO group, 30.3% received freeze-dried plasma and 23.4% received low titer group O whole blood, significantly higher than that in the PIV group. Prehospital mortality was 35.0% in the IO group. Univariable analysis showed significant associations with IO access for increased PIV attempts (OR = 1.69; 95% CI: 1.34 - 2.13) and signs of profound shock (OR = 11.0; 95% CI: 5.5 - 23.3). CONCLUSION: Profound shock signs are strongly linked to the need for IO access in prehospital settings with each successive PIV attempt increasing the likelihood of requiring IO conversion. IO access often accompanies low titer group O whole blood or freeze-dried plasma administration and higher prehospital mortality, indicating its use in emergent resuscitation situations. Early IO consideration is advised for trauma casualties with profound shock.

Intelligence among ear deformities and cleft lip and/or alveolus and/or cleft palate patients during 50 years in Israel.

PURPOSE: We evaluated hearing loss and general intelligence among persons with auricle anomalies and cleft lip and/or alveolus and/or cleft palate (CLAP). METHODS: A nationwide cross-sectional study of data recorded during 1966-2019, as mandatory pre-military recruitment of individuals. RESULTS: Of 3 182 892 adolescents, 548 were diagnosed with auricle anomalies and 2072 with CLAP. For the latter, the adjusted odds ratios for the low, low to medium and medium general intelligence categories compared to the highest category were 1.4 [95% CI 1.5-1.2], 1.2 [95% CI 1.4-1.1] and 1.1 [95% CI 1.2-0.9] respectively. The corresponding values for the auricle anomalies were not significant. CONCLUSIONS: General intelligence was impaired among individuals with CLAP, but no significant correlation was found among individuals suffering from auricle anomalies.

Acceptance of Seasonal Influenza Vaccine Following COVID-19 Vaccination: A Survey among Israel Defense Forces Soldiers.

Data regarding the contribution of COVID-19 vaccine rollouts to real-world uptake of influenza vaccination remains unclear. This cross-sectional survey-based study among Israel Defense Forces (IDF) soldiers aimed to assess the impact of the COVID-19 pandemic and specifically, previous COVID-19 vaccines uptake, on the intention to vaccinate for influenza during 2021-2022 season. Participants engaged in an online survey addressing vaccination history and current vaccine-related preferences. The survey was delivered prior to the initiation of the IDF's annual influenza immunization campaign. A multinomial logistic regression model was applied to analyze factors correlated with unwillingness to receive influenza vaccine. Overall, 825 invitations to participate in the survey were distributed and the overall response rate was 78.5%. Among the 648 participants who replied (61.6% males, median age of 20 years), 51.9% were willing to receive the upcoming influenza vaccine. Factors associated with vaccine reluctance included being female, not receiving the previous season's influenza vaccine, not having a previous diagnosis of COVID-19, and having decreased uptake of COVID-19 vaccines. Among participants not intending to receive an influenza vaccine, 50.3% stated that they are healthy and have no need for the vaccine and 36.2% stated they received too many vaccines over the previous year. The results of this study may suggest that influenza vaccination rates in the post-COVID-19 vaccine era may be reduced due to a perceived "vaccine saturation" phenomenon, owing to the density of COVID-19 vaccine administration. Future interventions such as campaigns related to maximizing influenza vaccination coverage should address repeated doses of COVID-19 vaccine administration.

Intraosseous administration of freeze-dried plasma in the prehospital setting.

BACKGROUND: Freeze dried plasma (FDP) is a commonly used replacement fluid in the prehospital setting when blood products are unavailable. It is normally administered via a peripheral intravenous (PIV) line. However, in severe casualties, when establishing a PIV is difficult, administration via intraosseous vascular access is a practical alternative, particularly under field conditions. OBJECTIVES: To evaluate the indications and success rate of intraosseous administration of FDP in casualties treated by the Israel Defense Forces (IDF). METHODS: A retrospective analysis of data from the IDF-Trauma Registry was conducted. It included all casualties treated with FDP via intraosseous from 2013 to 2019 with additional data on the technical aspects of deployment collected from the caregivers of each case. RESULTS: Of 7223 casualties treated during the study period, intravascular access was attempted in 1744; intraosseous in 87 of those. FDP via intraosseous was attempted in 15 (0.86% of all casualties requiring intravascular access). The complication rate was 73% (11/15 of casualties). Complications were more frequent when the event included multiple casualties or when the injury included multiple organs. Of the 11 failed attempts, 5 were reported as due to slow flow of the FDP through the intraosseous apparatus. Complications in the remaining six were associated with deployment of the intraosseous device. CONCLUSIONS: Administration of FDP via intraosseous access in the field requires a high skill level.

Tick-Borne Relapsing Fever Infection from a Bunker, a Case Report on a "One Health" Approach.

Background: Tick-borne relapsing fever (TBRF) caused by Borrelia persica is an endemic disease in Israel and highly prevalent in military personnel. Prevention among the Israel Defense Force soldiers is based on increased awareness mainly in hyperendemic areas and selective postexposure prophylaxis with doxycycline. In this study, we report the presence of a suspected outbreak of TBRF in four soldiers who spent 30 h inside a deserted bunker. Materials and Methods: Clinical data on TBRF suspected cases were retrieved from clinical records, soft ticks were collected using carbon dioxide (CO2) traps and their DNA was extracted and analysed by PCR and nucleotide sequencing. Environmental conditions such as relative humidity, air temperature, wind speed, and type of soil, as well as presence or absence of animal traces inside the bunkers were documented. Results: TBRF-like clinical symptoms in the patients included: tick bite scars, fever (37.5-39.2°C), rash, tachycardia, hypotension, myalgia, cough, headache, cervical lymphadenopathy and nausea. Microscopic search for B. persica in blood smears was performed in three patients and was negative. Out of the 255 Ornithodoros tholozani ticks collected from the bunker, 198 were analyzed and 2 (1%) were infected with B. persica. To determine if tick infestation in military bunkers is a common phenomenon, we surveyed nine additional military bunkers located in four different geographical areas for the presence of soft ticks. Only one additional bunker was infested with two O. tholozani ticks, both negative for B. persica. Presence of earth that probably helped sustain a relatively big tick population was observed on the floor in the highly infested bunker. Environmental treatment with lambda-cyhalothrin at 9.7% was performed and showed efficacy with no ticks recovered in the infested bunker 124 days after intervention. Conclusion: This study shows that military bunkers may harbor soft ticks infected with B. persica and entrance into bunkers should be considered as a risk for acquiring this infection like entrance into natural caves and archeological ruins.

Hearing Impairment and Severe Attention Deficit/Hyperactivity Disorder: A Nationwide Study.

BACKGROUND: The association between hearing impairment and attention-deficit/hyperactivity disorder (ADHD) is unclear. Therefore, we aimed to assess this association in Israel's national sample of over 1.1 million adolescents. METHODS: We conducted a nationwide, population-based, cross-sectional study of all Israeli adolescents (n = 1,175,534, 58% males; mean age, 17 yrs) who were examined before mandatory military service during 2004 to 2020. Board-certified specialists confirmed diagnoses of hearing impairment and severe ADHD. MAIN OUTCOMES AND MEASURES: We compared the prevalence of severe ADHD in adolescents with and without hearing impairment. Associations were analyzed using logistic regression models and sensitivity analyses accounting for hearing impairment type (sensorineural vs. conductive) and severity. RESULTS: Of the 8,769 adolescents with hearing impairment, 57 were diagnosed with severe ADHD (prevalence = 0.65%). Of the 1,166,765 adolescents without hearing impairment, 3,936 were diagnosed with severe ADHD (prevalence = 0.29%). We found a significant association between hearing impairment and severe ADHD (odds ratio = 1.93 [95% confidence interval, 1.47-2.49]), which persisted in a multivariable model adjusted to age, sex, socioeconomic status, educational status, cognitive performance, and immigration status (odds ratio = 1.70 [95% confidence interval, 1.29-2.20]). The association also persisted when stratified by hearing impairment type (sensorineural vs. conductive) and severity. CONCLUSIONS: Adolescents with hearing impairment had 70% increased odds of severe ADHD. Study findings suggest that active screening of patients with hearing impairment for ADHD should be considered.

Factors associated with failure of intraosseous access in prehospital trauma treatment by military medical personnel.

INTRODUCTION: Intraosseous devices have become an alternative to peripheral intravenous (PIV) access. Despite the established success of intraosseous devices in laboratory and simulator studies, there is a lack of data regarding their real-world utilisation in prehospital settings. Therefore, this study aims to evaluate the success rates of intraosseous access in a prehospital military context and identify factors associated with failure. METHODS: Using the Israel Defense Forces (IDF) Trauma Registry, we retrospectively collected data from 2010 to 2023. The primary outcome was the first pass success rate of intraosseous access, and logistic regression models were applied to identify variables associated with first pass failure. RESULTS: The study included 172 trauma patients who underwent attempted intraosseous access with 46.5% cases which were classified as military events. The median age was 22 years, and 17.3% were paediatric patients. First pass success was achieved in 67.4% of cases, with a cumulative success rate of 80.8% after multiple attempts. Moreover, significant differences were noted when examining the success rate of the three intraosseous devices used by the IDF teams, with the highest success rate being documented for the NIO Adult versus the EZ-IO or the BIG (81.4%; 76.7%; 62.4%). However, logistic regression analysis revealed that the number of PIV access attempts was the only variable significantly associated with decreased odds of achieving first pass intraosseous access. CONCLUSION: These findings suggest that intraosseous devices are a viable alternative for establishing vascular access in prehospital military settings. However, success rates were slightly lower than previous reports, potentially due to the severity of injuries in the study cohort. Our analyses revealed a higher number of PIV access attempts correlated with reduced first pass intraosseous success, possibly stemming from caregiver proficiency in obtaining vascular access. Further research is needed to explore additional factors affecting intraosseous access success rates.

Ventilating the Bearded: A Randomized Crossover Trial Comparing a Novel Bag-Valve-Guedel Adaptor to a Standard Mask.

INTRODUCTION: Emergency field ventilation using bag-valve face mask devices can be difficult to perform, especially in bearded individuals. In view of the increasing numbers of servicemen and civilians sporting a beard or moustache, the issue of finding a technical solution for ventilation in this population has gained importance. We therefore developed a novel adaptor that enables the direct connection of a bag-valve device to a Guedel-type oropharyngeal airway device thereby directly connecting the oral airway to the bag valve, eliminating the need for a face mask. The objective of this study was to compare the efficacy of the bag-valve-Guedel adaptor (BVGA) to the common face mask in healthy bearded volunteers. METHODS: This study was a randomized-by-sequence, crossover-controlled trial (NCT02768246) approved by the local IRB (0051-16-HMO). All subjects signed an informed consent before participation. Twenty-five healthy bearded men (age 28 ± 7) were recruited. After randomization, the first group (mask then BVGA, n = 12) began breathing room air through the face mask, followed by 100% O2. After washout in room air, the procedure was repeated with the BVGA. The second group (BVGA then mask, n = 13) began with the BVGA followed by the face mask. Subjects were awake and breathed spontaneously throughout the experiment. Therefore, a Guedel was not used. Physiological and respiratory parameters were monitored continuously. The primary endpoint was the presence of suspected leak as determined by end-tidal-CO2 (EtCO2 < 20 mmHg). Secondary endpoints included tidal volume and safety. RESULTS: The order of device use did not affect the results significantly (p > 0.05 by Mann-Whitney-U test); therefore, the data were pooled. There were no cases of suspected leak while breathing through the BVGA. By contrast, while breathing through a face mask, there were 8 of 25 (32%) and 5 of 25 (20%) cases of suspected leak in air and 100% O2, respectively (air: p = 0.002; 100% O2: p = 0.014 by McNemar test). No adverse events were observed. CONCLUSIONS: In bearded individuals, the BVGA provides significantly more efficient (less leak) ventilation compared to a face mask. This is also of particular importance in view of the increasing number of bearded individuals serving in the armed forces. Moreover, since effective ventilation with a mask requires experience, the relatively easy-to-apply BVGA will enable less experienced first responders to achieve higher success rates in this critical phase of treatment. Further studies are planned to evaluate the efficacy of the BVGA in the prehospital setting.

Hyperbaric oxygen therapy improves neurocognitive functions of post-stroke patients - a retrospective analysis.

BACKGROUND: Previous studies have shown that hyperbaric oxygen therapy (HBOT) can improve the motor functions and memory of post-stroke patients in the chronic stage. OBJECTIVE: The aim of this study is to evaluate the effects of HBOT on overall cognitive functions of post-stroke patients in the chronic stage. The nature, type and location of the stroke were investigated as possible modifiers. METHODS: A retrospective analysis was conducted on patients who were treated with HBOT for chronic stroke (>3 months) between 2008-2018. Participants were treated in a multi-place hyperbaric chamber with the following protocols: 40 to 60 daily sessions, 5 days per week, each session included 90 min of 100% oxygen at 2 ATA with 5 min air brakes every 20 minutes. Clinically significant improvements (CSI) were defined as > 0.5 standard deviation (SD). RESULTS: The study included 162 patients (75.3% males) with a mean age of 60.75±12.91. Of them, 77(47.53%) had cortical strokes, 87(53.7%) strokes were located in the left hemisphere and 121 suffered ischemic strokes (74.6%).HBOT induced a significant increase in all the cognitive function domains (p < 0.05), with 86% of the stroke victims achieving CSI. There were no significant differences post-HBOT of cortical strokes compared to sub-cortical strokes (p > 0.05). Hemorrhagic strokes had a significantly higher improvement in information processing speed post-HBOT (p < 0.05). Left hemisphere strokes had a higher increase in the motor domain (p < 0.05). In all cognitive domains, the baseline cognitive function was a significant predictor of CSI (p < 0.05), while stroke type, location and side were not significant predictors. CONCLUSIONS: HBOT induces significant improvements in all cognitive domains even in the late chronic stage. The selection of post-stroke patients for HBOT should be based on functional analysis and baseline cognitive scores rather than the stroke type, location or side of lesion.